Diagnosis: Sinus Tachycardia
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

This is an adult who presented to the hospital following a fall. She reported alcohol use on the night of the event and could not remember how she fell. She was found the following morning on the floor, unable to get up. Past medical history was significant for hypertension, congestive heart failure, and chronic obstructive pulmonary disease (COPD). Vital signs on arrival were stable (Blood Pressure 124/78, Pulse 97). Physical exam was significant for gait instability. A 12-lead electrocardiogram (ECG) revealed sinus tachycardia with left axis deviation and no ischemic ST (interval on ECG) or T (interval on ECG) wave abnormalities. Serum blood testing was significant for a mild elevation in Creatine phosphokinase (CPK) (305mg/dl [milligrams per deciliter]). Computed tomography (CT) of the chest revealed no evidence of pulmonary embolism. The patient was admitted to the hospital for monitoring and treatment. She was treated with intravenous (IV) and physical therapy.

No significant cardiac findings were noted on serum blood testing or ECG. The patient was discharged after observation for a two-day period. According to the European Society of Cardiology, this patient was a low-risk patient for future morbidity and mortality (Reference 1). In a study of individuals presenting to the emergency room with syncope and falls, patients that were low risk for cardiac events (no significant cardiac history of acute cardiac findings on initial evaluation) had an excellent prognosis and did not require admission to the hospital for further testing (Reference 2). In this case, the patient falls into a low-risk category and could be managed at a lower level of care.

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for inpatient admission services is not substantiated.